Winter respiratory vaccination strategy : autumn and winter 2022 to 2023

As we complete the spring booster programme and work towards the beginning of a new autumn campaign, it is a good time to review and reflect on our progress. As predicted, COVID-19 remains part of our lives as we try to get on and learn how to live with it. As we publish this latest strategy we are once again seeing an increase in cases and sustained pressure on our NHS, with the situation likely to worsen as we move into the autumn and winter. We are witnessing the impact of a surge of COVID-19 and influenza in the southern hemisphere and must take that as a warning and plan accordingly. 

Our vaccination programmes will always be guided by the latest clinical and scientific evidence and by the latest advice from the Joint Committee on Vaccination and Immunisation (JCVI) and the Chief Medical Officer for Wales. 

This strategy sets out our plans for autumn-winter 2022-2023 and how we will offer both the influenza (flu) and COVID-19 vaccines to those who are eligible, while being prepared to increase our capacity quickly, should we need to, in response to any future significant coronavirus pandemic wave or a new variant. We expect both COVID-19 and flu to circulate this winter and must be prepared for much higher or unseasonal flu activity. 

Therefore, this year, to protect the people of Wales and our health and care services I want to maximise the uptake of both flu and COVID-19 vaccines for everyone who is eligible. To help do this, where the availability of both flu and COVID-19 vaccines allow, some vulnerable groups will be offered both vaccines during the same appointment. Where this is not possible, we will ensure you are aware of where and how to get both these vaccines needed to keep you and others safe this autumn and winter. 

Deploying a Winter Respiratory Vaccination Programme this autumn is a significant step towards a fully integrated vaccination programme offering an improved experience, including greater convenience for patients and providing service efficiencies in the NHS. These longer-term changes will implement the good practice and lessons identified from existing vaccination programmes and the COVID-19 programme. 

We have accepted the JCVI advice to offer a COVID-19 autumn booster to residents and staff working in care homes for older adults, frontline health and social care workers, all those aged 50 and over and those aged 5 to 49 years in clinical risk groups.

In Wales we have once again repeated the extension of the offer of a flu vaccine to all adults aged 50 to 64 which we introduced last year. I am pleased that the JCVI advice means alignment in terms of age for both COVID-19 and flu vaccination for 2022, with both vaccines available to everyone over 50, so that all people in Wales at greatest risk from flu or COVID-19 will be eligible for vaccines protecting them against both winter respiratory viruses.

We must learn to live with endemic coronavirus, in the way we have been living with flu for many years. But there is more we can and must do still to reduce preventable death and serious illness caused by flu. An important way that we do that is through the protection offered by vaccination. Ensuring as many eligible people as possible come forward for both their flu and COVID-19 vaccinations will be critical to protect individuals, communities and our health and care services this winter.  

Our intention is to protect people from infection and prevent and reduce the impact of future waves, we hope that in doing so we will not need to implement surge plans for the NHS again this winter, but it is a possibility for which we must be prepared. Getting vaccinated when you are invited is a decision we can all take to protect ourselves and our families and continue to keep Wales safe.

Our national flu vaccination programme has been running for a much longer time than the COVID-19 programme. In the UK annual flu vaccination has been offered to individuals in the highest risk groups since the 1960s and to all people over 65 for more than 20 years. The childhood flu vaccination programme started 10 years ago and now includes children between the ages of 2 and 15, with the majority of this group receiving a flu vaccine at their school. There are many things learnt from the flu programme that underpin our successful COVID-19 programme. For example, our flu programme has strong links with health boards, school nursing teams, GPs and Community Pharmacies in Wales, who administer over one million flu vaccinations every autumn and winter. This experience helped establish the COVID-19 programme quickly and safely, giving everyone in the population who wanted the vaccine their primary and booster vaccines. 

Before the pandemic, flu caused significant pressures on our NHS in winter. The pandemic has made us much more aware that vaccination saves lives and reduces hospitalisations. Vaccination may not stop you catching coronavirus  or flu, but they make it far less likely that you will be severely ill or need hospitalisation if you do.

Both flu and coronavirus are respiratory illnesses that thrive in winter. Vaccines are available for both with those at higher risk of becoming seriously ill from these illnesses being eligible for vaccination. There are some differences in eligibility for the two vaccines, but everyone aged 50 and over is eligible for both. This alignment on the basis of age provides opportunities for co-administration of both vaccines, increasing uptake and providing greater health protection for our communities.

At the peak of the coronavirus pandemic, people prioritised getting vaccinated. The number of flu vaccines administered in the 2021-22 season was the highest ever recorded in Wales. High levels of vaccine uptake are important and continuing to achieve a high uptake will be a key priority this autumn to reduce severe illness and death, and to reduce hospitalisations during a time when the NHS and social care may again be managing winter outbreaks of COVID-19 alongside other winter viruses which will place pressure on services. Monitoring the data from Australia now, we expect that we could see much higher flu activity and we will have both coronavirus and flu circulating at the same time during winter when they pose the greatest threat. This is one of the reasons we are integrating our approach to COVID-19 and flu vaccination. 

We have published COVID-19 strategies at key points throughout the programme to set out our plans and to explain what you can expect. Similarly, for the flu programme, annual Welsh Health Circulars have been used for the Chief Medical Officer to set out priorities for and the expectations of the NHS.  

In our last strategy published in February 2022, we said we would look at the future provision of our vaccination services. As we move to a situation in which COVID-19 is endemic we were expecting COVID-19 vaccination will become a regular programme, with JCVI’s recent advice we can see this beginning to happen, provided the overall situation remains stable. We are also retaining the capability to stand up surge capacity if we need to respond to a new and significant COVID-19 wave, or outbreak of a new variant, even though we hope this capacity will not be needed again. This strategy sets out our aims for both the flu and COVID-19 elements of the programme. 

In line with JCVI advice, we have recently completed the offer of spring COVID-19 boosters to the oldest and most vulnerable people in Wales. Almost 85% of adults aged 75 and over and almost 84% of care home residents have taken up the offer of a spring booster. 

These figures are broadly comparable with other parts of the UK, and it is important that we understand those factors that influence levels of uptake amongst different groups in our society. We will therefore work with our Vaccine Equity Committee to review the evidence, and to consider how we can increase the take up rate of future vaccination programmes by further expanding access to the vaccine – this will include considering timing of appointments, the impact of prior infection and previous vaccinations, and understanding the impact of people’s changing priorities as well as the impact of the end of coronavirus restrictions throughout the UK.

Our vaccination programmes will always be guided by the latest clinical and scientific evidence and by the latest advice from the JCVI and the Chief Medical Officer for Wales.

We want everyone who is eligible for a vaccine to come forward and be vaccinated to protect themselves and others. For this autumn and winter our priority is to maximise uptake of both flu and COVID-19 vaccines for those who are eligible, especially for those most at risk of severe illness. We will monitor uptake of both vaccines, tracking key risk groups to make sure people and communities in Wales are well protected. We will act to improve uptake whenever we need to.  We know that delivering vaccines as close to communities as possible and clear communication about who is eligible for flu and COVID-19 vaccines and what the benefits of vaccination are helps people to come forward. 

We have three main priorities for our winter respiratory vaccination programme; these will be the vaccination campaigns we deploy:

• Protecting those at greatest risk
• Protecting children and young people
• Nobody left behind

While we cannot predict exactly what will happen with coronavirus or flu this year, we know that the elderly, vulnerable and those at greatest risk must continue to be our priority for vaccination. The evidence from Australia and concern from our Chief Medical Officer is such that we expect this winter to be another difficult one. 

The JCVI has recently provided its final advice on autumn boosters for COVID-19. They have continued to focus on individual risk and people caring for the vulnerable. Our NHS has plans in place to offer a COVID-19 autumn booster to the following adults in line with JCVI advice: 

• residents and staff working in care homes for older adults
• frontline health and social care workers
• all adults aged 50 years and over
• persons aged 5 to 49 years in a clinical risk group, including pregnant women
• persons aged 5 to 49 years who are household contacts of people with immunosuppression, as defined in the Green Book
• persons aged 16 to 49 who are carers

The JCVI also issues advice for flu vaccine and our NHS has plans in place to offer the flu vaccine to the following adults in line with this: 

• people aged 50 years and older 
• staff in nursing homes and care homes with regular client contact 
• staff providing frontline NHS/Primary care services, healthcare workers with direct patient contact
• staff providing domiciliary care 
• people aged six months to 49 years in a clinical risk group 
• individuals experiencing homelessness 
• pregnant women 
• carers 
• people with a learning disability 
• people with a severe mental illness 

We continue to expect all those working with our most vulnerable citizens to be vaccinated, this includes all health and social care employees; who, unless they have a medical reason that precludes them being vaccinated, have a professional obligation to be vaccinated to protect themselves and others. It will also help ensure resilience of our health and care services by minimising staff sickness during what is expected to be a difficult autumn and winter. Employers have an important role to play in encouraging staff to be vaccinated for both COVID-19 and flu. Employers can help by promoting vaccinations and supporting paid time off work to attend vaccination appointments. We will continue to do all we can to promote vaccination by voluntary means and make sure people have all the information they need to make an informed decision to get their COVID-19 and flu vaccinations.

There are no plans to vaccinate outside of the recommended groups, however, the JCVI will continue its rolling review of vaccination programmes and the epidemiological situation. Should we see a new variant appear in the autumn and winter which leads to rises in hospitalisations and death, then JCVI would consider the benefit of a wider vaccination programme. If this happens, we will receive further advice and will adapt our programme on that basis as we have with the COVID-19 programme at various points.

Our ambition

• We will offer the COVID-19 vaccine to all those that are eligible by the end of November
• We will offer the flu vaccine to all those that are eligible by the end of December 
• Our ambition is to achieve 75% take up across the board for both the COVID-19 and flu vaccine     
• Our ambition is to achieve 80% take up for the chronic obstructive pulmonary disease risk group for both the COVID-19 and flu vaccine

The approach we are proposing is consistent with the approach taken with previous COVID-19 strategy milestones. The uptake aim is set at 75% for both COVID-19 and flu, it is not a co-administration target or an amalgamated uptake target.  The milestone is in line with the World Health Organisation’s target of 75% for those aged 65 years and over for flu vaccine. 

The higher target for the chronic pulmonary obstructive disease (COPD) risk group is due to these individuals being particularly at risk if they contract a respiratory disease. Focussed efforts will be made to offer people with COPD both vaccines, with a view to maximising the protection they have against serious illness this year.  We will closely monitor the effectiveness of the approach we take for this group this year with a view to it informing wider deployment plans in the future.

We are focused on building confidence in vaccine uptake through our communications strategy so that people understand the importance of vaccination and take up their offers. This is alongside the ongoing commitment to ‘leave nobody behind’, with health boards undertaking mop up exercises to ensure vaccination remains accessible to anyone that wants it.

Throughout the pandemic routine vaccinations for babies and pre-school children continued, this is how important vaccination is in protecting children and young people. Children have the highest rate of infection from flu and flu can be serious for them. Complications can include bronchitis, pneumonia, and ear infections. Having a flu vaccine will not only help to protect children from getting flu, but it also helps stop them spreading it to their family, friends and the wider population.

Our NHS has plans in place to offer the flu vaccine to the following children in line with JCVI advice: 

• children aged two and three years 
• children in primary school from reception class to Year 6 (inclusive) 
• children and young people in secondary school Year 7 to Year 11 (inclusive) 
• people aged six months to 49 years in a clinical risk group 

Continuing to protect children and young people from flu is one of our priorities. For young children, the flu vaccine is given as a nose spray. The nose spray flu vaccine provides the best protection against flu for children aged 2 years and older. 

The COVID-19 vaccination eligibility for children will change for the autumn programme. The JCVI has recently provided their final advice on autumn boosters and, in line with this, our NHS has plans in place to offer a COVID-19 autumn booster to the following children: 

• persons aged 5 to 49 years in a clinical risk group
• persons aged 5 to 49 years who are household contacts of people with immunosuppression or carers

The JCVI will continue to keep the situation under review as regards vaccination of children and young people.

The nobody left behind principle has been a feature throughout the COVID-19 vaccination programme. It will be carried forward into the Winter Respiratory Vaccination Programme. It means that the opportunity for eligible individuals to come forward for their vaccine will not expire and that the NHS will continue to seek out high uptake levels by making the vaccine available and accessible.  

There is a flu and COVID-19 vaccination available for every eligible person. This principle remains key in our vaccination strategy.  We monitor uptake and trends to ensure everyone has fair access and fair opportunity to take up the offer of vaccination.  

For example, the data currently shows there is a lower uptake of COVID-19 vaccination among younger people and lower uptake of flu vaccination among social care staff.  We are working with partners to understand the barriers to vaccination in order to develop interventions to maximise take up amongst these groups. We have a role to play in ensuring the decision to turn down the offer of vaccination is an informed choice rather than due to a lack of access or mis-information about the efficacy or impact of immunisation. We have also supported the Keep Wales Safe ‘street teams’ campaign, an engagement initiative whereby ‘street teams’ talk to people in under-served communities to understand the barriers to vaccination, which is a critical first step to increasing uptake and ensuring vaccine equity.  

We know that COVID-19 affects different population groups in Wales in different ways and the NHS has worked closely with community groups and leaders, responding to local issues such as:

• vaccine mis-information leading to hesitancy among some community groups
• lack of transport to vaccination centres resulting in some being unable to attend a vaccination appointment
• mis-trust of health professionals leading to some people feeling anxious about attending mass vaccination centres 
• time constraints leading to others finding they could not prioritise a vaccination appointment.  

With the help of partners, interventions have been developed to address such barriers. For example:

• factual information has been co-produced to address fears
• webinars have been held 
• community leaders have been engaged to help increase knowledge and achieve acceptance
• drive-in centres and walk-throughs operating long opening hours have been utilised in many areas allowing people to choose the best time to take up the offer of a vaccine
• mobile and pop-up clinics in shopping, faith and community centres have been used extensively bringing vaccination closer to communities
• smaller community clinics have been offered giving those experiencing specific language or cultural barriers the opportunity to take up the offer of vaccination

These innovative and effective delivery models will continue as we integrate COVID-19 into our existing vaccination programme, expanding the success of the programme to other vaccinations to maximise uptake.  

As we roll out our Winter Respiratory Vaccination Programme in the autumn, health boards will build on the work currently being undertaken with a range of partners and community voices to encourage those eligible to come forward for vaccination, including those who haven’t yet had a COVID-19 vaccine. A sample of actions currently being taken by health boards to engage with communities and under-served groups include:  

• Close engagement with school nurses and youth officers within the Hywel Dda Health Board area to provide parents, children and young people with advice, links, easy read and videos on the vaccination process.
• Cwm Taf Morgannwg Health Board are undertaking outreach work through its Black, Asian and Minority Ethnic outreach team as well as Local Authority and third sector Community Cohesion teams.
• Mobile vaccination delivery vehicles are being deployed within the Besti Cadwallader Health Board area to target areas such as industrial business parks, supermarkets, hostels and socio-economically deprived communities. A specific focus on Foodbank clinics has been very effective in reaching those who have not yet received their first or second dose of the COVID-19 vaccination.
• Multiple pop-up vaccination clinics are being used by Aneurin Bevan Health Board which are being advertised locally in 17 different languages. Two dedicated clinics have been held in Magor for the Ukrainian refugees. All Ukrainians known to have settled in the area have been sent a letter inviting them to take up the offer of a vaccine at a mass vaccination centre.
• Given the rural nature of Powys the local health board are enabling people to access their vaccine with support from organisations such as Community Transport.
• Cardiff and the Vale Health Board continue to run their ‘Seldom heard voices’ campaign to target underrepresented groups such as those experiencing Homelessness, Travellers, Asylum seekers, Black, Asian and Minority Ethnic communities, Carers, People with sensory loss, Communication-Language, Transgender communities and people with Mental Health illnesses. The health board also continue to work with ‘Safer Wales’, to vaccinate sex workers and a sensory POD has been created at Bayside mass vaccination centre.
• Swansea Bay Health Board is deploying home visiting teams to help support individuals experiencing severe anxiety and are continuing to operate their ambulance service taking vaccination out to local venues such as a shopping centre, rugby club and the local swimming pool.

Throughout the pandemic the Vaccine Equity Committee, using data and behavioural insights, has advised on bespoke interventions to engage with under-served communities, and will continue to monitor uptake and trends to see if there is more we can do. The committee is informed by the latest available evidence, including Public Health Wales’ quarterly surveillance report on vaccine uptake by sex, socio-economic deprivation and ethnicity. 

To support the integration of flu and COVID-19 vaccinations under the Winter Respiratory Vaccination Programme we are expanding the remit of the Vaccine Equity Committee to include flu. This will facilitate a regular focus on uptake data and potential barriers to vaccination to support our aim of ensuring every eligible person has fair access and fair opportunity to take up the offer of vaccination in Wales.

Our ambition 

• We will continue to work to ensure nobody is left behind and maximise vaccine coverage in Wales for the protection of individuals, their families and the communities in which they live.

Different vaccines are given in different places, this is because of different reasons, such as patient age, vaccine type and available workforce. The majority of flu vaccinations will be given by primary care, this includes GP surgeries and pharmacies. Health boards will give the majority of COVID-19 vaccinations at vaccination centres. This is what we have come to expect and are used to for both flu and COVID-19. Having a blended model of delivery works well for our vaccination programmes, supporting the NHS to deploy models that are suitable for their communities, enabling them to reach into communities and helping people to access their vaccines. 

In the JCVI’s final advice for COVID-19 autumn boosters they have said that co-administration of COVID-19 and flu vaccines should take place where possible. Where we are able to do this, we will. Last year, many healthcare workers and care home residents had their COVID-19 and flu vaccines at the same time. This co-administration was efficient for our NHS to deliver and gave patients more protection in one appointment, providing an increased level of convenience for individuals. 

This year we will build on this and aim to co-administer flu and COVID-19 vaccine to those who have chronic obstructive pulmonary disease (COPD). COPD is a condition that affects the respiratory system, which means they are particularly at risk of serious illness should they contract a respiratory virus.  That is why we have decided to target co-administration of both vaccines at individuals with COPD.  

Vaccines are not mandatory, so it will not be mandatory for individuals to have two vaccines in the same appointment, but if you are offered both we encourage you to choose to have both to increase your protection. Having the flu and COVID-19 vaccines co-administered may be more convenient for many people, especially our health and social care workforce. 

You will be invited to your COVID-19 vaccination by letter when there is one ready for you. For COVID-19 adults need an interval of 28 days between known COVID-19 infection and vaccination. Spring boosters have been carefully planned and timed to ensure enough time is left between the two doses. 

You may already know if you are eligible for a flu vaccine, there is more information available on the Public Health Wales website to find out about getting your flu vaccine.

We know it is important people can access their vaccine appointment at a time and place which suits their personal circumstances and needs. We continue to ask people to prioritise appointments wherever possible, but we understand this is not always possible. 

Our ambition

• We will work to maximise co-administration of flu and COVID-19 vaccines, and specifically target patients with COPD given their increased risk.

Subject to continuity of COVID-19 vaccine supply, we will ensure sufficient and appropriate vaccine formulation for primary course doses, and boosters. Our COVID-19 vaccines are procured by the UK Government on behalf of the Four Nations to ensure a cost-efficient approach. We will consider the advice from the JCVI concerning the availability and suitability of vaccines and will work with the other parts of the UK to ensure the availability of the most appropriate vaccine, including new vaccines in development to target variants. 

Every year flu vaccines are reviewed to best target forecasted circulating flu strains. The vaccines currently in use for Australia are a good match for the strains circulating which increases efficacy of the vaccination programme. Subject to availability of flu vaccine supply, we will work with health boards, GPs and community pharmacies, who procure flu vaccine directly, to ensure sufficient and appropriate vaccine supplies are available. The flu vaccine used for children aged 2-15 is procured by the UK Government on behalf of the Four Nations to ensure a cost efficient approach. We will continue to look at innovative ways to ensure flu vaccine supply is the most efficient for maximising uptake.

Our NHS has plans in place to deliver the winter respiratory vaccination programme outlined in this strategy. There are also plans in place in case we need to surge capacity in response to a new variant or significant new wave in the pandemic. We hope we do not need to use those plans, but the NHS is prepared. 

Provided the COVID-19 situation remains stable, we hope that this year is the first year of an integrated annual booster programme for both COVID-19 and flu for certain eligible groups. Not all the population will need a vaccine again this year.  However, the JCVI will continue to monitor the situation and keep the public health response under review. 

Currently there are multiple vaccination programmes delivered by NHS Wales. Many of the pre-COVID-19 programmes are highly successful in reducing mortality and morbidity from vaccine preventable diseases. However, there are opportunities for improvement across all vaccination programmes in Wales including from the COVID-19 and from the more well-established vaccination programmes, such as flu and the paediatric immunisation programmes.

The integration of the COVID-19 and flu programmes this year is the first step in our vaccination transformation programme. The vaccination transformation programme is how we look at the provision of our vaccination services as a whole and for the longer term to ensure our services are fit for the future. Vaccination services are essential to protect us from severe disease and we need individuals to have trust and confidence in information provided to come forward for vaccination.

In the autumn we will publish a National Immunisation Framework for Wales. The Framework is being developed on a co-construction basis with the NHS. Through this process we will identify and use what works well currently and the lessons from the pandemic to transition to a position of improved business as usual through integrating all current vaccination programmes. The Framework will be applied across the NHS in Wales so that the people of Wales have an identifiable and seamless provision to obtain their vaccination to ensure protection from viruses.    

The design principles for the National Immunisation Framework are:

• Person centred services: where people recognise the importance of vaccination, can access their record, know which vaccinations they are due and are able to identify ways to get vaccinated as close to home as possible .
• Inclusion and engagement central to service design and delivery: local and national infrastructures and systems in place to enable inclusion and engagement to be at the root of our vaccination services in Wales.
• Centrally developed framework delivered locally: overarching national framework with flexibility for tailored interventions at a local level to meet local population needs.
• Value-based approaches which provide return on investment: recognising the inherent value element of vaccination in preventing disease and ensuring value for money in the approaches deployed.
• Data driven and evidence-based approach: timely, accurate data and behavioural insights provided to ensure the service is person centred, innovative and effective.
• Partnership working: Ongoing and meaningful engagement with partners to ensure person centred services that deliver outcomes and value for money.
• Continuous improvement: evaluation of approaches undertaken regularly to understand impact on behaviours, sharing best practice and adapting deployment models when necessary.
• Digital solutions to support the operation of services and improve patient experience: with digital solutions complying with industry best standards, including in terms of the Welsh language, whilst supporting access for those who are digitally excluded.

Existing good practice will be the foundation of the service transformation, as will the knowledge of key people working within these services and the need to harness their expertise is crucial.  

Our ambition

• Our ambition for the vaccination transformation programme is to deliver world-leading outcomes in vaccine preventable disease by establishing a National Immunisation Framework for Wales by 2023.

It is important people make informed choices about vaccinations based on accurate and trusted information. We continue to work with Public Health Wales and NHS Wales to make sure such information is easily available, tailored by age and circumstance. It is crucial people feel informed about the effects of a vaccine, their eligibility and know how to access their vaccine when called. 

Public Health Wales has patient information for COVID-19 and flu, and helpful FAQs about vaccines and safety.

We have a blended delivery model and locations of vaccination centres may change, some health boards will use more local centres rather than larger centres. Health boards will have up to date information on local arrangements on their websites and social media so people will know where and how to access their vaccination offer.

We remain committed to being transparent and keeping everyone up to date with progress. We will:

• Release a weekly summary of data on COVID-19 vaccinations. This will be published on the Public Health Wales dashboard. This will show the total cumulative number of vaccinations administered, although the actual number of people vaccinated will be higher due to ongoing data entry.
• Release regular flu surveillance reports. These will be published on the Public Health Wales flu webpage. It will summarise flu activity and show vaccination uptake rate by group during the autumn and winter season. 
• Release an enhanced surveillance report to support our nobody left behind work for COVID-19 vaccinations, this will also be published on the Public Health Wales dashboard. 
• Publish Ministerial statements explaining when there are new developments or changes to the Winter Respiratory Vaccination Programme. 
• Publish vaccination updates once a term.